Evaluation Questionaire, LC Technologies, Inc.

Eyegaze Communication System

EVALUATION QUESTIONNAIRE

If you are interested in being contacted by a registered nurse to discuss an evaluation with the Eyegaze System, please print and fill out the following questionnaire and mail or fax it to LC Technologies.

Please answer the following questions to aid us in assessing the client's potential successful use of the Eyegaze Communication System.

GENERAL INFORMATION:

Name:____________________________________________________________________________

Sex:________ Age: ________ Date of Birth: _____/_____/_____ Phone:______________________

Street Address:______________________________________________________________________

City, State, Zip:______________________________________________________________________

Education Level:_______________________ Prior/Current Occupation:________________________

PHYSICAL STATUS:

Brief medical history/diagnosis:

_________________________________________________________________________________

_________________________________________________________________________________

Current physical condition including description of limitations:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Current medications (please include dose and times of day administered):

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

List any current physical discomforts:

_________________________________________________________________________________

_________________________________________________________________________________

Number of hours per day that client spends in chair:_________ wheelchair:_________ bed:_________

Does client wear contact lenses? Yes________ No_______ If yes, hard?______ soft?_______

Does client wear glasses for reading? Yes________ No ________ Bifocals? Yes______ No_______

Is client able to keep head steady for 5 seconds or longer? Yes_______ No_______

Describe type and amount of head motion (e.g. spasticity, athetoid movements, no movement):

_________________________________________________________________________________

_________________________________________________________________________________

Is client able to maintain eye contact with you for a second or more? Yes_____ No______

Describe client's eye control (e.g. steady gaze, drifting eye, nystagmus, etc.):

_________________________________________________________________________________

_________________________________________________________________________________

Can he/she direct his/her gaze in all directions? Yes_____ No_____ If no, explain:

_________________________________________________________________________________

_________________________________________________________________________________

Do his/her yes appear to track together? Yes_____ No_____ If no, describe:

_________________________________________________________________________________

_________________________________________________________________________________

Does client have a "dominant" eye? Yes_____ No_____ If yes, Left?_____ or Right?_____

Does client have cataracts? Yes_____ No_____

Does client maintain normal eye moisture? Yes_____ No_____ Explain, if necessary:

_________________________________________________________________________________

COMMUNICATION SKILLS:

Is client able to read? Yes _____ No _____ Unknown at present_____

Please describe how client currently communicates "yes" and "no":

_________________________________________________________________________________

_________________________________________________________________________________

How does he/she communicate other things?

_________________________________________________________________________________

_________________________________________________________________________________

Is client able to follow directions? Yes_____ No_____

Does client seem motivated to be able to communicate more effectively? Yes_____ No_____

How does he/she usually respond to new people?

_________________________________________________________________________________

_________________________________________________________________________________

Describe any speech capabilities:

_________________________________________________________________________________

_________________________________________________________________________________

Please list prior communication devices used and level of success/failure experienced:

_________________________________________________________________________________

_________________________________________________________________________________

Other information that you think will be helpful:

_________________________________________________________________________________

_________________________________________________________________________________

Person Filling out Questionnaire:

Name:____________________________________________________________________________

Daytime Phone:____________________

Relationship (Father, Mother, Caregiver, etc.): ________________________________________

Full Address:______________________________________________________________________

If you have questions, call:

Nancy Cleveland, R.N., B.S.N.

(800) 393-4293 or (703) 385-7133

Contact Information:

LC Technologies, Inc
1483 Chain Bridge Road
Suite 104
McLean, Virginia 22101 U.S.A.

Voice: 703-385-7133 or
800-EYEGAZE (800-393-4293)

FAX: 703-288-3727

Email: requests@eyegaze.com

Web Service online since January 1996

This address is http://www.eyegaze.com/2Products/Disability/questionnaire.html

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